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Ophthalmic Plastic and Reconstructive Surgery 3(3):135-140.
1987. ~ 1987 Raven Press, Ltd., New York
William P. Chen, M.D., F.A.C.S.
on Anatomy and Techniques
Summary: Recent advances
in the understanding of eyelid anatomy in Caucasians and Asians are presented.
Various techniques of lid crease operations are then described. A modified
technique, combining excision of the skin, orbicularis, orbital septum,
and preaponeurotic fat pad, and coupled with supratarsal fixation of the
skin to the levator aponeurosis, is used by the author to achieve more
predictable and long-lasting postoperative results.
blepharoplasty-Blepharoplasty- Double-eyelid operation-Lid crease-Superior
palpebral fold. From Long Beach, California, U.S.A.
and reprint requests to:
Dr. William. P.
2865 Atlantic Avenue. Suite 220
Long Beach, CA 90806 USA
Recent advances in
the understanding of eyelid structure and anatomy have allowed eye surgeons
to apply this knowledge toward more predictable surgical results. We have
come to realize that the upper eyelid complex consists of skin, subdermal
fat and connective tissue, orbicularis oculi, orbital septum, preaponeurotic
fat pads, levator aponeurosis and muscle, Mueller's muscle, and conjunctive.
It is postulated that
the lid crease is formed by attachment of levator aponeurosis fibers onto
the orbicularis and subcutaneous tissues underneath the skin, and this
appears to be supported by anatomic cross sectional studies (1). We realize
that there are basic differences between Asian and Caucasian eyelids in
that in a significant percentage of Asians, sometimes reaching 70%, the
distal aponeurotic insertion is often rudimentary or absent, leading to
the absence of a lid crease as found in Caucasians. An excellent study
was recently published by Doxanas (1). He proposed that in Asians the
orbital septum tends to fuse with the levator aponeurosis at a lower level
on the anterior surface of the superior tarsus, thereby allowing preaponeurotic
fat to migrate further down. This prevents the distal aponeurotic fibers
from attaching anteriorly onto the orbicularis and subcutaneous tissues
to form the lid crease. This gives the impression that Asians have more
orbital and preaponeurotic fat. Figure la illustrates the absence of a
lid crease, as seen in Asian eyelids. Figure lh shows a lid crease in
a Caucasian eyelid. The lid crease, when present, may be continuous (Fig.
1b discontinuous (Fig. lc), incomplete (Fig. ld), or multiple (Fig. 1e).
It may slant down or flare up at either canthal angle. Zubiri (2) used
the term "foldless" or "inside fold" to describe a crease that tapers
toward the medial canthal angle, as in Fig. If, and "outside fold" or
"parallel fold" to describe a lid crease that stays parallel over the
medial canthal angle (Fig. la). Asians frequently appear to have a shortened
palpebral fissure owing to the presence of an epicanthal fold nasally,
which fans out gently into the creaseless skin or merges into a shallow
crease. It is significant that because of interracial marriages, one may
see different subsets of the above findings. In lid fold procedures and
blepharoplasty among Asians, the goal should therefore be to create an
aesthetically pleasing lid crease that is in balance with the person's
facial and orbital contour, one that complements the palpebral fissure,
while maintaining a slight upslant of the lateral canthus in relation
to the medial canthus.
In the last 30 years,
different authors have described drastically different techniques in an
attempt to create a lid crease, the permanency of such being as important
as the aesthetic appeal. Sayoc (3) in 1953 described the technique where
a skin muscle incision is made down to the tarsal surface, followed by
excision of a strip of pretarsal orbicularis muscle. He then attached
the inferior skin edge to the tarsal surface using 7-0 silk or 6-0 chromic
catgut. Fernandez (4) in 1960 modified this by excising some skin, and
the lid crease was formed by deliberate attachment of skin to the levator
aponeurosis. With eyelids that appeared full, he routinely excised a small
strip of orbicularis, septum orbitale, and preaponeurotic fat. Boo Chai
(5) in 1964 used only three nylon sutures from the conjunctival surface
toward the skin side to create the lid crease, not unlike Pang's full-thickness
eyelid sutures used in conjunction with blepharotomy. Mutou and Mutou
(6) in 1972 claimed only 0.1% failure rate when they used two silk or
catgut sutures, placing them horizontally from the conjunctival surface
and parallel to the superior tarsal border, and burying the ligatures
on the conjunctival side. It is, however, the opinion of most surgeons
that this method has a higher incidence of failure with disappearance
of the lid crease. Flowers (personal communication per J. S. Zubiri, 1977)
described excising the orbicularis and orbital septum, detaching and then
reattaching the levator aponeurotic insertion on the tarsal plate. This
is an overly drastic maneuver without any added advantage while at the
same time creating the risk of lid contour deformity and secondary ptosis.
Matsunaga (7) described a procedure of creating a supratarsal fold that
is followed by removal of the epicanthal fold several months later.
The technique of performing
lid crease enhancement in Asians should be tailored to the lid anatomy
of the individual patient; this is the key to good results and a satisfied
patient. In the preliminary evaluation of these patients, it is important
to elicit any history of wound-healing irregularity, keloid formation
and hypertrophic scar, systemic illnesses, steroid intake, allergic blepharoconjunctivitis,
keratitis sicca, and any contraindication to surgery. One should then
examine the patient and note the presence or absence of epi (FIG. 2. A
strip of redundant skin being excised above the lid crease incision line.)
(FIG. 3. The orbital septum is opened and a small amount of preaponeurotic
fat removed.) canthal fold, characteristics of the lid crease (contour,
extent, single or multiple, distance from the lid margin, nasal "dip,"
etc.), presence of eyelid fullness from excessive preaponeurotic fat,
shallowness of orbital rims, nasal bridge, intercanthal distance, and
whether there is a natural upslant of the lateral canthus. The author
usually asks the patient to show him where they want the crease to be:
whether they prefer the crease to be parallel or tapered at the medial
canthal angle, and to be parallel or flare up at the lateral canthal angle.
The surgical technique
consists of the following sequence of maneuvers: After adequate anesthesia
is achieved, the lid is everted, and the tarsal plate is measured carefully
with a calipers over the central, lateral, and medial portions. It is
then transposed onto the skin side, which will constitute the new lid
crease position. The lateral extent of the lid crease is made parallel
or slightly higher than the central portion. Any excessive skin is marked
out in an elliptical fashion. (FIG. 4. Supratarsal fixation. The stitches
includes small portions of the levator aponeurosis between the upper and
lower skin edges.) (FIG. 5. Closure of lid crease with 7-0 nylon in a
continuous fashion) The author tries to stay within 8 mm from the lateral
canthus. The skin removed usually does not exceed 3 mm (Fig. 2). The epicanthal
fold is left untouched in the majority of cases. A 2- to 3-mm strip of
pretarsal orbicularis muscle below the level of the superior tarsal border
is then excised. The upper edge is pulled up slightly with a fine skin
retractor, exposing the orbital septum, and again 2 mm of it is excised
at its point of fusion with the distal levator aponeurosis. Excessive
fat is removed (Fig. 3) by careful clamping, cutting, electrocautery,
and reinspection for bleeding points. Supratarsal fixation is then carried
out by the use of nonabsorbable sutures (Fig. 4). The author uses four
6-0 silk in an interrupted fashion, picking up the lower skin edge with
small bites of the levator aponeurosis and then the upper skin edge; 6-0
nylon or polypropylene is used in those that tend to form hypertrophic
scars and keloids. The rest of the closure consists of 7O silk or nylon
in a running fashion, and the crease usually forms very nicely (Fig. 5).
Stitches are removed (FIG. 6. Fifteen-year-old girl with absence of lid
crease (top). Postoperative result (bottom).) by the end of 5 days for
silk and 7 days for polypropylene or nylon. Postoperative swelling and
ecchymosis are usually confined to the pretarsal portion of the lid incision
and will recover in 4 weeks when the vascular and lymphatic channels reestablish
themselves. (FIG. 8. Preoperative (top) and postoperative (bottom) views
of 25-year-old woman who had had two previous lid crease procer1'~r"~:)
(FIG. 7. Twenty-two-year old woman with indistinct lid crease (top). Postoperative
photo (bottom) was taken 3 weeks after repair. Routinely the author advises
patients to stop consuming any aspirin and anticoagulants for 2 weeks
prior to and I week after the surgery. Diuretics and low-dose corticosteroids
are seldom indicated postoperatively. The various methods described for
excision of the epicanthal folds are all less than satisfactory as they
create unsightly scars that cannot be easily hidden. The maneuver of transcribing
the superior tarsal border onto the skin side for the lid crease incision
will not result in an excessively high crease since the upper tarsus of
most Asians measures between 6 and 8 mm. Potential complications include
infection, hemor rhage, suture reaction, granuloma formation, secondary
ptosis, lid retraction, and corneal exposure. Suboptimal results include
uneven lid creases, insufficient lid crease, insufficient excision of
fat pads, redundant lid creases, lid creases that disappear with time,
unsightly epicanthal scar, and lash ptosis. In certain patients, there
may be rarefaction or Partial disinsertion of the levator aponeurosis,
and this must be corrected accordingly.
Figure 6 illustrates
the preoperative appearance and ideal, postoperative result on a 15-year-old
girl who underwent a lid crease procedure. Note the gentle tapering of
the crease at the medial canthus, merging into the epicanthal fold. Figure
7 shows a 22-year-old woman who desired enhancement of her lid crease.
The postoperative photo was taken 3 weeks after surgery and showed residual
edema and slight ptosis. Both resolved by 6 weeks postoperatively. Figure
8 is of a 25-year-old woman who had had two previous lid crease corrections.
She complained of excess downward sloping of her lid crease that caused
it to appear fused to the lateral canthus. Correction was performed by
enhancing the crease laterally and placing it at a higher level. Figure
9 shows the appearance of a 43-year-old woman with excessive hooding of
her upper lid that caused obliteration of the lid crease. A blepharoplasty
was performed. Figure 10 shows a 32-year-old man before and after the
creation of a lid crease. Note the slightly lower placement of the crease;
no attempts were made to remove any preaponeurotic fat pads.
In summary, the goal
of the surgeon should be to create an attractively placed eyelid crease
that is well suited to the Asian facial and eyelid configuration, and
to avoid an excessively high lid crease with its round eyed appearance.
The technique described in this article has yielded predictable and permanent
results in the hands of the author.
- Doxanas MT. oriental
eyelids. An anatomic study. Arch Ophthalmol 1984;102:1232-5.
- Zubiri JS. Correction
of the Oriental eyelid. Cling Plast Surg 1981 ;8:725-37.
- Sayoc B. Plastic
construction of the superior palpebral fold. Bull Phil Ophthalmol Otol
- Fernandez L. Double
eyelid operation in the oriental in Hawaii. Plast Reconstr Surg 1960;25:257.
- Boo Chai K. Plastic
construction of the superior palpebral fold. Plast Reconstr Surg 1964;31:556.
- Mutou Y. Mutou
H. Intradermal double-eyelid operation and its follow-up results. Br
J Plast Surg 1972;25:285.